OTC Substance Abuse—
Current Issues and
Prevention Strategies
Brian Fingerson, RPh
KYPRN Kentucky Professionals Recovery Network
There is a unique disconnect
between the scientific facts
and the public’s perception about
drug abuse and addiction
Drug abuse is a preventable behavior
Drug addiction is a treatable disease
Partnership for a Drug-Free America
http://www.drugfree.org/
Initial drug use is a
voluntary behavior…
A person chooses to
take a drug for the first time
Why do people take drugs in the
first place?
People Take Drugs To:
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Feel good (sensation seeking)
Feel better (self-medication)
A major reason people take
a drug is they like what
it does to their brains
Prolonged drug use changes
the brain in fundamental and
long-lasting ways
Addiction is a Developmental
Disease—Typically Begins in
Childhood or Adolescence
Five Things to Know About
Adolescents’ Brain Development and Use
Thomas J. Crowley, MD, and Elizabeth Whitmore, PhD
http://www.hbo.com/addiction/
Five Things to Know About Adolescents’
Brain Development and Use
1. The brain’s “front end,” the part above the eyes
(prefrontal cortex), exists to slow us down or stop
our impulsive behaviors; it considers the risks and
benefits of our actions, and it helps us "hit the
brakes" when we consider doing things that are
too risky.
2. This part of the brain is still developing
connections to the rest of the brain until
adulthood, so adolescents’ brains lack some of the
“wiring” that carries “brake” or “stop” messages
to the rest of the brain.
http://www.hbo.com/addiction/
Five Things to Know About Adolescents’
Brain Development and Use
3. Drugs of abuse are often available to
adolescents; these drugs feel good, but they
can be very harmful. Lacking some of the
wiring for the "stop" message, adolescents’
brains may not fully weigh the risks of drug
use. (if it feels good – do it )
4. The two drugs that cause the most death are
also the most available drugs: tobacco and
alcohol. Late adolescence, before the brain is
fully matured, is the peak time for developing
dependence on these (and other) drugs.
http://www.hbo.com/addiction/
Five Things to Know About Adolescents’
Brain Development and Use
5. Heavy drug use during times of critical
brain development may cause
permanent changes in the way the brain
works and responds to rewards and
consequences. Therefore, it is important
to begin to address a developing
substance use problem as early as
possible.
http://www.hbo.com/addiction/
Over-the-Counter Drug Abuse
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OTC drugs, especially cough and cold
medications, are becoming very
popular as recreational drugs
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Especially for young teenagers 13 to 16
years of age
Hospitals have reported dozens of
overdoses in the past 2 years
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Including five deaths where the abuse of
OTC medications was a factor
Emergency Departments 2005
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An estimated 598,542 U.S. ED visits in
2005 involved the nonmedical use of
prescription or OTC pharmaceuticals
or dietary supplements
21% higher than 2004 estimates
from the SAMHSA 2006 National Survey on Drug Use
and Health (NSDUH)
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In 2006, about 3.1 million persons aged 12 to 25 (5.3
percent) had ever used an over-the-counter (OTC) cough and
cold medication to get high (i.e., “misused” the drug), and
nearly 1 million (1.7 percent) had done so in the past year
Among youths aged 12 to 17, females were more likely than
males to have misused OTC cough and cold medications in
the past year, but among young adults aged 18 to 25, males
were more likely than females to have misused these
medications
Among persons aged 12 to 25 who had misused an OTC
cough and cold medication in the past year, 30.5 percent
misused a NyQuil® product, 18.1 percent misused a
Coricidin® product, and 17.8 percent misused a Robitussin®
product
Erowid Psychoactive Vaults
www.erowid.org
Erowid’s Site
Oral DXM Dosages
Threshold
Unknown
Light
100–200 mg
Common
200–400 mg
Strong
300–600 mg
Heavy
600–1,500 mg
Risk of Death 2,500–20,000 mg
http://www.erowid.org
Erowid Guide to DXM
in Nonprescription Drugs
Version 1.6 — June 15,
2004
 93 products and
ingredients listed for
DXM products only
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Erowid’s Guide
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Introduction
For those who choose to use DXM
recreationally, it is extremely important to
pay attention to the active ingredients list
of the brand they choose to use. People
knowledgeable in the field recommend that
only products containing DXM alone
(sometimes listed as 'Dextromethorphan
hydrobromide') in the Active Ingredients
list should be used.
http://www.erowid.org
Gel Cap Dosages
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Drixoral Cough Liquid Caps© – 30 mg
DexAlone© – 30 mg
Robitussin Cough Gels© – 15 mg
Cough Syrups
OTC DXM content ranges from
7.5 mg per 5 ml to
15mg per 5 ml, so…a 240ml
bottle would be 360-720mg of
DXM
Triple C’s or Coricidin Cough
and Cold©
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Contains:
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Chlorpheniramine maleate 4 mg
Dextromethorphan hydrobromide 30 mg
Other Coricidin products contain
acetaminophen and/or guaifenesin
“This product should not be used as a
source for recreational DXM”— Erowid
DXM Plateaus
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A term used by those who abuse DXM
Describes experiences associated with
different recreational dosages (exceeding
recommended dosages)
Experiences at different plateaus range from
mild distortions of color and sound to visual
hallucinations, “out-of-body” dissociative
sensations, and loss of motor control
The third plateau is what many DXM users
strive for, often described as the most “mindopening”
http://www.third-plateau.org
DXM Effects
Positive
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Mood lift, euphoria
Giggling, laughing
Dissociation of mind from body (positive when
sought)
Visual and aural hallucinations (positive when
sought)
Creative dreamlike experiences
Some users report empathic feelings, forgiveness,
warm feelings toward others
DXM Effects
Neutral
 Pupil dilation
 Confusion, disorientation
 Skin sensitivity, alters tactile (touch) and
skin sensations
 Robotic, zombie-like walking, "robo-walk"
 Discoordination, reduced agility
DXM Effects
Negative
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Upset stomach, vomiting
Dizziness
Decreased sexual functioning (difficulty achieving orgasm)
Body itching
Rash, red blotchy skin
Diarrhea
Fever
Tachycardia (racing, pounding heart)
Some users report feeling disconnected, isolated from others
Some users report hangover/depression on the following 1-2
days
Restricting DXM Sales
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Oklahoma considering a bill that would ban
the sale of any cough medicine containing
DXM, as well as spray paint, to anyone
under the age of 18 years
New York, other states, considering similar
legislation
Throughout the country
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Some stores require ID showing the purchaser
is at least 18 years of age
Some place DXM products behind-the-counter
Inhalant Abuse: Definition
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Commonly known among kids as "huffing,"
"bagging," or "sniffing"
The deliberate concentration and inhalation
of common products found in homes,
offices, and schools to get high
Inhalant Abuse: Statistics
National surveys of young people and U.S.
households indicate that:
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Among high school students, inhalants are 5th most-abused
substance after alcohol, tobacco, marijuana, and prescription
drugs
Almost as many 8th graders have ever tried inhalants (16%)
as have tried marijuana (18%), according to Monitoring the
Future 2003
According to the 2002 Household Survey, 308,000 teens,
aged 12–17 used inhalants in the past month
Fewer than 1 in 20 parents believe their children may have
ever abused inhalants (denial or ignorance?)
Why Do Young People
Abuse Inhalants?
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Products are legal, widely available,
inexpensive, and easy to conceal
Most users do not realize how
dangerous inhalants are
Many young people start because
they don't think these substances can
hurt them
>1,000 Common Products Are
Potential Inhalants That Can Kill
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Glue
Freon
Correction fluid
Computer agents
Deodorizers
Markers
Paint products
Gases (whippets,
butane, propane)
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Gasoline
Fire extinguishers
Nail polish remover
Lighter fluid
Hair spray
Cleaning agents
Inhalant Abuse:
Harmful Effects
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Chronic inhalant users can suffer severe
and permanent brain damage; some die the
first time they experiment
Other possible risks include:
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Intoxication
Hearing loss
Bone marrow damage
Short-term memory loss
Limb spasms
Liver and kidney damage
Laxatives
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Laxative abuse is a common feature
of eating disorders
Although it is a behavior associated
with bulimia, many anorectics and
even over-eaters use or occasionally
use laxatives
Laxative Abuse Problems
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Severe abdominal pain
Chronic diarrhea/loss of rectum control after
repeated use of laxatives
Bloating
Dehydration
Gas
Nausea, vomiting
Electrolyte disturbances which can lead to heart
arrythmias and heart attacks
Chronic constipation
What Are Energy Drinks?
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Contain large doses of caffeine and
other legal stimulants
Beverages such as Red Bull, Venom,
Adrenaline Rush, 180, ISO Sprint,
and Whoop Ass
Other Energy Drink Ingredients
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B vitamins
Ephedra
Glucuronolactone
Ginseng
Green tea
Guarana
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Inositol
L-tyrosine
Sugar
Taurine
Yohimbine
Various others
“The Legal Alternative”?
http://www.drinkcocaine.com
Caffeine Content of
Cocaine Energy Drink©
An 8.4 oz can of Cocaine Energy Drink contains
280 mg of caffeine
Cocaine is a new energy drink from Redux
Beverages
Available in an 8.4 oz (250 mL) can, the drink
claims that it is 350% stronger than a Red Bull
FDA Action
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Warning letter issued April 4, 2007
Claims Cocaine energy drink is marketed as a
dietary supplement
“Street drug alternatives, i.e., products that
claim to mimic the effects of recreational
drugs, are not intended to supplement the
diet and, as a result, cannot lawfully be
marketed as dietary supplements.”
FDA states that Cocaine energy drink is a
new drug requiring an application to the FDA
http://www.fda.gov/foi/warning_letters/b6312d.htm
Redux Beverages LLC Response
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Language that FDA cited removed
from Web site
New information states:
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“Cocaine energy drink is an energy
supplement following the guidelines set
forth by the federal Food and Drug
Administration for dietary supplements…
It is not designed for or intended to be
used to diagnose, treat, cure, mitigate, or
prevent any diseases.”
http://www.drinkcocaine.com April 23, 2007.
And now:
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‘Cocaine’ drink yanked from shelves
nationwide
Company plans to rebrand the energy
beverage after FDA complaints
Here is the latest
'Cocaine' energy drink renamed
as 'Censored'
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The makers of the energy drink "Cocaine"
have announced that they will be changing
the name in response to criticism and
pressure from the FDA and state officials
saying the name glamorized illegal drug
use. So, appropriately, the new name will
be "Censored," because it has the "same
rebellious and fun spirit" as the old name.
Caffeine Doses
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Oral Caffeine Dosages
Threshold
10–20 mg
Common 50–150 mg
Strong
150–400 mg
Heavy
400+ mg
Lethal
3–20 g oral (estimated,
see below)
LD50 (lethal dose) 192 mg/kg in rats
Onset : 5–10 minutes
Duration: 1.5–5 hours
Normal after effects: up to 24 hours
Caffeine Effects: Positive
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Reduces boredom (Loke 1988)
Decreases depression
Increased alertness when tired (Wesenten 2005,
Kamimori 2005)
Willingness to consider alternative theories
(Martin 2006)
Increases physical stamina and reduces perceived
exertion (McLellan TM 2004)
May attenuate the response-slowing effect of
alcohol (Roehrs 2004)
Increases performance on boring, repetitive tasks
(Smith 2002)
Caffeine Effects: Neutral
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Research has failed to show improved
memory or improvement in complex
cognitive tasks
Smith A. Food Chem Toxicol. 2002;40:1243–55.
Caffeine Effects: Negative
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Increases anxiety and nervousness at high
doses or in sensitive individuals (Loke 1988)
Insomnia, decreased ability to sleep (Smith
2002)
Caffeine withdrawal can worsen mood (Schuh
1997)
Caffeine withdrawal causes headaches, flu-like
symptoms, feelings of lethargy and reduces
motivation (Schuh 1997)
Increases jaw tension and bruxism (Erowid
Self Reports 2000, Ohayon 2001)
Ephedra/Ephedrine/
Pseudoephedrine
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Ephedra is used as a stimulant and for mild
respiratory disorders, including asthma and
bronchitis
In Asian medicine, it is used for fever,
swelling, and bone pain
Ephedrine, the principle alkaloid, a popular
ingredient in many "herbal" weight loss
and body building formulas, decongestants,
"legal high" alternatives, and ephedrinebased pep pills
Negative Effects of Ephedra
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Potential side effects include sleeplessness,
restlessness, irritability, headache, nausea,
vomiting, urinary disorders, and rapid
heartbeat
Higher doses can stimulate a sharp rise in
blood pressure and disrupt heart rhythm
Chronic use can lead to tolerance and
dependence, requiring ever larger doses to
obtain earlier effects
Because of these dangers, ephedra should
be used only for short periods of time
Salvia divinorum Effects
Positive
 Short duration (when smoked)
 Radical perspective shifting
 Increase in sensual and aesthetic
appreciation
 Creative dreamlike experience
 Insight into personal issues
http://www.erowid.org
Salvia divinorum Effects
Neutral
 Powerful open and closed eye visuals
 General change in consciousness (as with most
psychoactives)
 Altered perceptions
 Change in body temperature, flushing
 Sensation of physical push, pressure, or wind
 Sensation of entering or perceiving other
dimensions, alternate realities
 Feeling of 'presence' or entity contact
 Dissociation at high doses, walking, or standing
http://www.erowid.org
Salvia divinorum Effects
Negative
 Overly intense experiences
 Fear, terror, and panic
 Increased perspiration
 Possible difficulty integrating experiences
 Higher doses can cause inability to control
muscles and maintain balance; falls are
reported
http://www.erowid.org
Posting on You Tube
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Salvia Divinorum
Short student documentary about Salvia
Divinorum...salvia divinorum documentary
salvia divinorum documentary
Time: 07:59
Salvia an “Outlaw Drug”
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It has been put into DEA Schedule I in
a number of states - effective 1 Jan.
‘08 it is Schedule I in Illinois
Erowid keeps users abreast of what is
legal or illegal based on location
Many Other Legal Alternatives
http://www.drugabuse.gov
For More Information
National Institute on Drug Abuse
Public Information Office
301-443-1124
or
http://www.nida.nih.gov
http://www.drugabuse.gov
National Clearinghouse on Alcohol and
Drug Information
http://ncadi.samhsa.gov
800-729-6686
Online Resources
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http://www.erowid.org
http://www.third-plateau.org
http://www.usaprn.org
http://family.samhsa.gov
http://ncadi.samhsa.gov
http://www.casacolumbia.org
Take Home Messages
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Drug abuse is a preventable behavior and
drug addiction is a treatable disease.
Addiction is a developmental disease
typically beginning in childhood or
adolescence.
Children and adolescents have access to
information on misuse and abuse of
substances that are widely available and
legal to obtain.
Thank you!
“Recovery” by Michael Vye
Brian Fingerson, RPh
KYPRN
502-749-8385
kyprn@insightbb.com
How Prevalent
Is Cough Medicine Abuse?
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Nearly 1 in 10 teens (or 2.4 million)
reported abusing cough medicine to
get high in 2005
Partnership for a Drug-Free America
http://www.drugfree.org Partnership Attitude Tracking Study
What Can Pharmacists Do?
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Be aware of the issues
Provide education regarding the potential
abuse and misuse of medications and other
products
Evaluate product placement in the
pharmacy
Be aware of suspect purchases
Provide education to parents and
community groups
What Can Faculty Do?
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Prepare students to address this issue
when they enter practice
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Awareness
Educational strategies
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Role plays
Develop fact sheets
Public service announcements
Others